1. Field of the Invention
The present invention relates medical instruments and, more particularly, to an instrument for inserting a chest drainage tube.
2. Description of Related Prior Art
Conventional chest drainage tubes typically include a plurality of apertures at the distal end for inflow of fluid within the parietal pleura and effect drainage. Heretofore, the insertion of the chest drainage tube has been primarily a manual function performed by the surgeon. This operation will be summarized below to emphasize the function and utility of the present invention.
An incision is made at the level of the fifth intercostal space overlying the sixth rib. In men, this is about at the nipple line and in women it is at the level of the xiphoid process or inframammary fold. The incision is made just anterior to the mid-axillary line in a horizontal fashion.
Betadine or chlorhexidine is used as the topical antibacterial/disinfectant prior to the procedure. The chest wall is widely prepped to ensure sterility. The patient's arm on the ipsilateral side (same side as placement of the drainage tube is placed) is elevated above the patient's head to allow for adequate access. The incision is made with a scalpel of approximately 3 cm in length after injection of local anesthetic into the skin, subcutaneous tissue, and just above the rib. Once this is done, dissection through subcutaneous tissue over the rib is done with a Kelly clamp. It is important to dissect the rib above the skin incision to offset the skin incision from the pleural incision so that when the chest drainage tube is pulled out eventually, the two openings do not line up. Further blunt dissection is carried out through the intercostals muscles with the clamp, during which time it is important to keep the clamp riding along the cephalad border of the rib so as to avoid damage to the intercostals vein, artery, and nerve. These structures are collectively known as the neurovascular bundle.
The parietal pleura is then carefully punctured with the clamp tip and the opening enlarged with a gloved finger. A 360 degree sweep is made to check the visceral pleura, lung surface, and any palpable adhesions. The chest drainage tube is then inserted with a clamp on the distal end, either with the aid of a finger or by following the path previously made. A second clamp may be placed on the proximal end (outside of the patient's body) if fluid is expected so as to prevent spillage. Once inserted through the parietal pleural opening, the distal clamp may be removed and the chest drainage tube advanced apically/cephalad. The chest drainage tube is inserted to at least 12 cm to ensure that all drainage holes on the tube are within the chest. For this reason, in very large patients the insertion may be 16 cm or more, and in smaller patients the insertion may need be only 10 cm.
The proximal clamp is then removed and the end of the chest drainage tube placed in a suction canister. The position of the chest drainage tube is verified by looking for tube condensation indicating good placement. Often times, the chest drainage tube is also rotated to confirm placement as it should turn freely if not kinked.
The chest drainage tube is sutured in place with the skin with a series of knots in silk suture and the end of the chest drainage tube placed to underwater seal or suction (−20 mm water), if not already done. A chest x-ray is taken to confirm proper position and function of the chest drainage tube. If needed, the chest drainage tube can be withdrawn if too far in the chest. It is never further advanced due to the risk of introducing skin contaminants into the chest.
Hemothorax (blood in the inter-pleural space) will often drain without wall suction (blood is forced out with respirations as the lung expands). Pneumothorax (air in the inter-pleural space) requires suction until no air leak remains.